Lecture 78 - Esophageal Disease Flashcards
(28 cards)
Symptoms of esophageal diseases:
Heartburn (pyrosis) –
Regurgitation – acidic fluid in mouth with recumbency or bending over
Chest pain –
Dysphagia – difficulty swallowing
Odynophagia – retrosternal pain with swallow
Differences in dysphagia: motor vs mechanical
Mechanical Dysphagia = Narrowing of the esophagus
Progression of dysphagia starting with solids
Motor Dysphagia == movement disorder of the esophagus Presents gradually; can be with solids or liquids
GERD:
What is it?
risk factor for…
describe the pathophysiology in relation to two anatomic/functional barriers of reflux
Symptoms and or esophageal mucosal damage secondary to reflux of normal gastric content
Risk factor for adenocarcinoma
Two barriers for Anti-Reflux: The Crura of the Diaphragm; Lower esophgeal Sphincter Primary problem: most commonly related to transient lower esophageal sphicter relaxation Other Reasons: Hiatal hernia --
aside from LES Tone and a hiatal hernia, what other co-factors can contribute to GERD?
Poor Esophageal Clearance – (eg body position, perstalisis, poor salivation)
Gastric factors -- acid, gastric distention, poor gastric emptying External factors -- medications can effect LES tone, diet, smoking, obesity These are preventable and treatable with life style modifications
Briefly describe the presenation differences between classic GERD, extra esophgeal GERD, and complicated GERD …
how does this affect how you would proceed with diagnosis?
Classic GERD — all the typical esophageal symptoms (heart burn, post prandial, worse with laying down)
Extra esophgeal GERD: asthma, hoarse voice, etc
Complicated GERD: dysphagia, odynophagia, bleeding –
the latter requires immediate attention via endocoscpy
the first two – proceed with empiric therapy, and assess effectiveness
Treatment of GERD
Life style Modification: diet, weight loss, sleeping with elevated HOB
Medical: H2RA, PPI
Maintenance therapy is required
Diagnosis of GERD:
clinical dx strategy vs potential diagnostic tests
Empiric Therapies
tests: Barium Swallow (not good for GERD) Manometry -- not good for GERD; testing the motility of the esophagus
Endoscopy –
Ambulatory pH Monitoring for 24 hours (measuring acid)
Impedance pH Study (measuring pH and non pH reflux)
4 complications of GERD
- Erosive/ulcerative esophagitis
- Esophageal (peptic) stricture
- Barrett’s esophagus
- Adenocarcinoma
Peptic Stricture:
- pathology
Treatment-
• Gradual narrowing of the distal esophagus due to scarring from chronic acid-induced injury and repair
patients with poorly controlled GERD
• Treatment with of aggressive medical antireflux therapy and endoscopy with dilation
Barrett’s Esophagus:
what is it? pathophysiology
risk factor for…
• Metaplastic columnar epithelium (intestinal metaplasia) replaces squamous epithelium in the distal esophagus
* GER injures squamous epithelium and promotes repair by columnar metaplasia * Occurs in ~ 10 % of patients with GERD symptoms who have endoscopy * Risk factor for developing esophageal adenocarcinoma
what are two cancers of the esophagus?
discuss their epidemiology – (demographics); location in the esophagus they are most likely to occur
risk factors for each
Adenocarcinoma, – M»_space; F, white > blacks, lower esophagus
Adenocarcinoma – GERD, obesity, tobacco;
Usually Barrett’s esophagus is present predating the cancer
Persons with Barrett’s – 40 -125 x increased risk
Squamous Cell Carcinoma – M>F, Blacks>whites, Mid esophagus
SCC – alcohol and tobacco,
Pathophysiology of Adenocarcinoma
Barrett’s Esophagus – evolve through a sequence of genetic alternations; which is seen as dysplasia phases and other morphology on histology
Barrett’s –> Low grade dysplasia –> High Grade Dysplasia –> Adeno
Presentation of Esophageal Cancer:
Dysphagia — Solid foods and the progresses over weeks to months to liquids
odynophagia, CP, anorexia, Weight loss
Treatment: of Esophageal Cancer:
Early / local – combined modality – radiation, chemotherapy, surgery
Late/beyond the esophagus – esophgeal dilation ( esophageal stent, laser
Provide good palliation of symptoms
4 Esophageal Motility Disorders:
Achalasia – d/o of LES relaxation
Distal Esophageal spasm – spastic or uncoordinated d/o
Nutcracker or Jackhammer Esophagus : hypercontractility d/o
Scleroderma: hypocontractility d/o
Key Diagnositic test for assessment of Esophageal Motility ?
Esophageal Manometry
Conventional vs High Resolution Manometry
what is being measured and by what parameters
Conventional – LES pressure, LES relaxation, Wave Progression (is it peristaltic), Wave amplitude (relaxation/contraction force),
High Resolution
Distal Contractility Integral – Used to assess contractile strength over time (similar to amplitude)
Integrated Relaxation Pressure – assessment of relaxation after swallowin
Achalasia
Patholophysiology
Diagnosis (characteristic appearance of the LES)
Treatment
failure of relaxation of the LES due to loss of inhibitory motor neurons (ganglion cells; myenteric/aurbach plexus) in the body of the esophagus at the LES
leading to dysphagia (solids and liquids together)
Diagnosis: dilated esophagus with debris;
Tight lower esophageal sphincter
Birds Beak – tight narrowing of the LES,
Treatment:
Myotomy
Pneumatic dilation
Uncoordinated/spastic d/o: (Diffuse Esophageal Spasm)
&
Hypercontractile d/o (nutcracker or jackhammer esophagus)
who gets these?
Commonly associated with?
most common symptom?
EPI — ages 30-40; Female Predominance; Frequenctly seen with IBS and psychiatric d/o
Symptoms
Chest pain – atypical, non-cardiac — in 80 - 90 % of cases
Dysphagia
Heart Burn
Dx and evaluation DES/nutcracker/jackhamer
what is required for the dx?
what might be seen on barium swallow?
manometry is required for dx
barium swallow:
DES - -might corksscrew
Cardiac eval – rule out heart disease
manometry of:
Diffuse Esophageal Spasm
vs
Nutcracker/Jackhammer esophagus
DES – Manometry
intermeittent normal peristalsis with intermittent spastic contractions
Nutracracker or JackHammer Manometry:
Normal Peristalsis with very high contractile index (Amplitude)
Treatment of Diffuse Esophageal Spasm
vs
Nutcracker/Jackhammer esophagus
Treatment: Reassurance – this isn’t heart disease
Pharmacotherapies – don’t work that well
Endoscopic/surgical – sometimes
Hypocontractile d/o— Scleroderma:
what is it?
what is seen on manometry?
Systemic connective tissue d/o with esophageal motor dysfunction
Manometry:
Weak contractions of the esophagus (similar to achalasia)
Almost absent LES tone (opposite of achalasia)
therefore present with GERD symptoms
three other causes of esophagitis?
Infectious –viral (CMV, HSV); fungal (candida)
Pill esophagitis
Eosinophilic esophagitis
